Optimal surgical treatment of rectal cancer is important to control local disease and preserve voiding and sexual function with a good quality of life. Anal sphincter preservation is a challenging issue in distal rectal cancer. Preoperative combined multimodality treatment might increase the rate of anal sphincter preservation. Postoperative adjuvant therapy with chemoradiation in stage II and III seems to increase survical rates and decrease local failure. To achieve the best oncologic and functional outcomes, the extent and type of surgery must be chosen based upon accurate preoperative staging of rectal cancer. Early cancer can be managed with minimal invasive surgery, however, neoadjuvant chemoradiation therapy on patients with locally advanced rectal cancer can improve resectability and oncologic outcomes. The rate of local failure is markedly decreased with the development of sharp pelvic dissection and the concept of total mesorectal excision. Total mesorectal excision is to remove rectal cancer and surrounding mesorectum completely without interruption of the rectal proper fascia. Optimized surgical technique and adjuvant chemoradiation can guarantee a promising oncologic outcomes ; however, difficulties of management of patients with local or systemic failure still remain.